Healthcare Provider Details

I. General information

NPI: 1497647580
Provider Name (Legal Business Name): JERRICA LANDE AU.D., CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

7163 SUNSHINE DR
EDEN PRAIRIE MN
55346-2755
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-4082
  • Fax:
Mailing address:
  • Phone: 218-230-8083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number9195
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: